Hindawi Publishing Corporation

ISRN Psychiatry
Volume 2013, Article ID 246358, 7 pages
http://dx.doi.org/10.1155/2013/246358

Clinical Study
Age of Onset of Mood Disorders and Complexity of
Personality Traits

L. Ostacoli,1 M. Zuffranieri,1 M. Cavallo,1,2 A. Zennaro,3 I. Rainero,4 L. Pinessi,4

M. V. Pacchiana Parravicini,1 E. Ladisa,1 P. M. Furlan,1 and R. L. Picci1
1
Department of Mental Health, “San Luigi Gonzaga” Hospital Medical School, ASL TO3, University of Turin,
Regione Gonzole 10, 10043 Orbassano, Italy
2
Department of Translational Medicine, “Amedeo Avogadro”, University of Eastern Piedmont, Via Solaroli 17, 28100 Novara, Italy
3
Department of Psychology, University of Turin, Via Verdi 10, 10124 Torino, Italy
4
Department of Neuroscience, “Neurology II”, University of Turin, Via Cherasco 15, 10126 Torino, Italy

Correspondence should be addressed to M. Zuffranieri; mzuffranieri@gmail.com

Received 20 February 2013; Accepted 18 March 2013

Academic Editors: B. Amann, B. Biancosino, and C. M. Contreras

Copyright © 2013 L. Ostacoli et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective. The aim of the present study is to evaluate the link between the age of onset of mood disorders and the complexity of the
personality traits. Methods. 209 patients with major depressive or manic/hypomanic episodes were assessed using the Structured
Clinical Interview for DSM Axis I diagnoses and the Millon Clinical Multiaxial Inventory-III (MCMI-III). Results. 17.2% of the
patients had no elevated MCMI-III scores, 45.9% had one peak, and 36.9% had a complex personality disorder with two or more
elevated scores. Mood disorders onset of 29 years or less was the variable most related to the complexity of personality disorders
as indicated from a recursive partitioning analysis. Conclusions. The relationship between mood disorders and personality traits
differ in reference to age of onset of the mood disorder. In younger patients, maladaptive personality traits can evolve both in a
mood disorder onset and in a complex personality disorder, while the later development of a severe mood disorder can increase
the personality symptomatology. Our results suggest a threshold of mood disorder onset higher compared to previous studies.
Maladaptive personality traits should be assessed not only during adolescence but also in young adults to identify and treat potential
severe mood disorders.

1. Introduction disorders can lead to the early development of severe medical

Mood disorders (MD) such as depression and bipolar dis-
orders are one of the most disabling types of diseases [1].
In 2004, depression was the leading cause of disability as
measured by years lost due to disability (YLD) and the 3rd
leading contributor to the global burden of disease assessed
using the disability-adjusted life year (DALY), a time-based
measure that combines years of life lost due to premature
mortality and years of life lost due to time lived in states
of less than full health [2]. Bipolar disorder was one of the
top 10 leading global causes of YLD in 2004 [2]. Presence
of risk factors (e.g., excessive nicotine use and alcohol and
other drug use), cooccurring anxiety disorders, and eating
conditions [3].
Also personality disorders (PD) are a class of disorders
that can significantly worsen a patient’s quality of life. In fact,
psychosocial impairment is one of the diagnostic criteria for
personality disorders according to the DSM IV [4] and there
is empirical evidence that the most severe personality dis-
orders (e.g., schizotypal personality disorder and borderline
personality disorder) are a major cause of psychosocial dis-
ability compared to unipolar depression without personality
disorders [5].
Both clinical practice and empirical studies show that
there is often interdependence between MD and PD [6–9].
Data from National Epidemiologic Survey on Alcohol and
2 ISRN Psychiatry
Related Conditions showed cooccurrence rates of lifetime
prevalence of three PD (Borderline, Narcissistic, and Schizo-
typal) with any MD ranging from 17.2% to 10.3% [10–12].
However, to date the nature of this interdependence still
remains unclear.
One of the reasons for the interest in this issue is
to contribute to improve treatments. Empirical evidence
reports a tendency of poor outcome in case of cooccur-
rence of depression and PD compared to patients with a
diagnosis of depression only [13]. This has been attributed
either to worse compliance of pharmacological therapy [14]
or to the difficulty of maintaining an active and efficient
social support, which could protect against relapses [15, 16].
Moreover, there is some evidence that the presence of
PD, especially of the avoidant type, interferes with treat-
ment response at interpersonal psychotherapy of depression
[17].
Several hypotheses have been suggested to understand
MD-DP relationship. Among others, Lewinsohn and col-
leagues [18] proposed that low levels of mood could have
a “scar effect” on individuals: PD could develop probably
by one’s modification of coping and appraisal styles. From
another perspective [19], it is argued that some maladaptive
personality traits could be seen as risk factors of developing
both an MD and also a true PD.
Recently it has been suggested that the age of onset of
MD could be a more efficacious criterion of classification
than polarity [20]. This opens interesting perspective not
only for clinical studies but also for treatment. Unfortunately,
the studies that have explored the age of onset of MD are
not many and, with the exception cited above [20], have
investigated bipolar or unipolar samples separately, with an
implicit assumption of the polarity criterion. Moreover, the
common denominator of these studies was a priori deter-
mined thresholds that could explain the clinical difference
in terms of severity or comorbidity found between patients
who have developed the disorder at different ages. Fava and
colleagues [21] found a higher prevalence of PD in patients
who had earlier onset of major depressive disorder (below
18 years) compared to patients with later onset. This result
was not replicated by Skodol and colleagues [22] who instead
found that severity and recurrence of major depressive
disorder were predictors of borderline personality disorder.
Perlis and colleagues [23] have compared bipolar disorder
patients with very early onset with patients whose onset was
after the age of 18 finding a poor outcome in the first group
in terms of fewer days of euthymia and greater impairment
in functioning and quality of life. In a recent study, Bukh
and colleagues found higher comorbidity of personality
disorder between patients with relative early onset of MD
[24].
The main goal of the present study is to evaluate the asso-
ciation between the age of onset of MD and the complexity
of the personality traits of the patient. Secondly, we will be
interested in identifying an age threshold able to maximize
the differences between early and later onsets in terms of the
complexity of the personality traits. Lastly, we will explore the
association between mood disorder severity and personality
traits.
2. Materials and Methods
2.1. Participants. The patients for the study were recruited
in three psychiatric wards in Piedmont (Italy). Patients
consecutively admitted for Major Depressive Episodes or
Manic/Hypomanic Episodes between April 2006 and April
2007 were considered.
Inclusion criteria were age over 18 and an agreement
to participate in the study with informed consent, whereas
patients diagnosed with schizophrenia and other psychotic
disorders, chronic substance abuse, severe medical illnesses,
or cognitive disorders were excluded from the study. The
study was approved by the ethic committees of the hospitals
involved in the study, and written informed consent was
obtained from all participants.
2.2. Measurements. Axis I diagnoses were evaluated with
the Structured Clinical Interview (SCID-1) for DSM-IV [25].
Results of a recent study [26] showed that SCID-I validity was
high and that interrater reliability ranged from .60 to .83. The
following data were also gathered: age, sex, and educational
level. Age at onset of depression or mania/hypomania, num-
ber of episodes of each type, average duration of each phase of
illness, number of admissions for mood disorders, and family
history of psychiatric illness were assessed by an anamnestic
interview controlled whenever possible with corroborating
family reports and medical records.
The severity of the mood disorder was analyzed in terms
of age of onset, duration of episodes, and frequency of
episodes.
All the participants included in the study were admin-
istered the Millon Clinical Multiaxial Inventory-III [27, 28].
The MCMI-III is a 175-item true/false self-report instrument
that assesses Axis I and II psychopathology. The MCMI-
III identifies 14 personality disorder scales and 10 clinical
syndrome scales. The MCMI-III raw scores are transformed
and reported as weighted base rate (BR) scores. Good internal
consistency (𝛼 = .66–.90) and stability (test-retest 𝑟 =
.84–.96) have generally been found for the MCMI-III scales
[27].
A recent study (Zennaro, in press), carried out on the
Italian version of MCMI-III, shows that the inventory falls
short in assigning PD categorical attributions to patients. The
reason of such results can be found in BR cutoffs used to
determine the presence of traits versus the presence of PD dis-
orders. Otherwise the cited study shows how MCMI-III can
correctly and reliably distinguish between pathological and
not-pathological individuals. Even for this reason, MCMI-
III was used with the most elevated anchor point with the
purpose of exploring personality traits rather than assigning
a diagnosis.
The severity of the personality traits was indeed analyzed
in terms of complexity of the PD [29], with reference to the
number of dimensions of the MCMI-III with a BR score
of 85 or above. According to MCMI-III scoring guidelines,
patients with BR scores of 85 or above on any of the
MCMI-III personality scales (i.e., schizoid, avoidant, depres-
sive, dependent, histrionic, narcissistic, antisocial, aggressive,
compulsive, passive aggressive, self-defeating, schizotypal,
ISRN Psychiatry 3

Table 1: Sample characteristics and clinical data relative to the MD for PD complexity.

𝑁 = 209 No PDa PD Simpleb PD Complexc Total 𝑃 Effect Size

𝑁 (%) 36 (17.2%) 96 (45.9%) 77 (36.9%) 209
Gender (F) 27 (75.0%) 61 (63.5%) 55 (71.4%) 143 (68.4%) .207 .015
Age 53.70 (11.39) 57.97 (12.72) 53.36 (13.83) 55.54 (13.07) .044 .030
Years of education 9.14 (3.07) 8.56 (3.02) 9.06 (3.11) 8.85 (3.06) .464 .007
Employed 8 (22.2%) 29 (30.5%) 25 (32.5%) 62 (29.7%) .378 .009
Depressive disorder
Single episode 6 (16.7%) 9 (9.4%) 7 (9.1%) 22 (10.5%)
Recurrent 24 (66.7%) 51 (53.1%) 34 (44.2%) 109 (52.2%)
Bipolar disorder
Type I 3 (8.3%) 20 (20.8%) 24 (31.2%) 47 (22.5%)
Type II 3 (8.3%) 16 (16.7%) 12 (15.6%) 31 (14.8%) .084 .053
Age of MD onset 35.42 (12.83) 40.36 (19.92) 32.47 (15.01) 36.60 (15.46) .003 .055
Years of illness 18.25 (15.12) 17.64 (14.58) 21.05 (13.53) .326 .011
Number of episodes annual (mean) (𝑁 = 187) .81 (.91) .59 (.51) .68 (.65) .66 (.64) .231 .016
Average duration of episodes (𝑁 = 187) .334 .025
(≤1 month) 5 (16.7%) 13 (14.8%) 8 (11.6%)
(≤3 months) 16 (53.3%) 44 (50.0%) 27 (39.1%)
(>3 months) 9 (30.0%) 31 (34.5%) 34 (50.0%)
a
Participants with none elevation on the MCMI-III.
b
Participants with one elevation on the MCMI-III.
c
Participants with more than one elevation on the MCMI-III.
𝜒2 and 𝜑2 were used for the comparison of categorical variables; ANOVA 𝐹 test and 𝜂2 were used for the comparison of continues variables.

borderline, paranoid) are to be considered personality disor-
der elevated. The sample was thus divided in three groups:
participants with none, one (i.e., simple PD), or with more
than one (i.e., complex PD) elevations on the MCMI-III.
MCM-III was administered just before discharge and
after the patients had recovered from the affective episode.
2.3. Power Calculation. To have 90% power to detect an effect
size of 0.30 in the comparison of complexity of PD with six
hypothetical nodes produced by recursive partitioning with
two-sided significance level alpha of 0.05, we required about
200 patients [30].
2.4. Analysis. Descriptive analyses of the demographic and
clinical variables were performed. The shape of the distri-
bution of the continuous variables was evaluated, and com-
parisons amongst the three groups defined by the MCMI-III
scores were done.
After excluding patients with a single major depressive
episode, who could not be analysed in terms of duration and
number of episodes, a recursive partitioning analysis [31] was
used to find the most characterizing variables for the different
complexity distributions of the PD. The recursive partitioning
analysis was realized with the party procedure ([32] (for a
methodological description of procedure), [33]) of the system
for statistical computation and graphicsR [34].
To study the individual contribution of each variable to
the prediction of the complexity of the personality disorder, a
factorial analysis of variance was performed. After a graphical
inspection, a logarithmic transformation was applied to the
continuous variables which had a nonnormal distribution
(i.e., the age of onset of the MD and the average number
of episodes per year). In the model, the dependent variable
is a dichotomous variable: disease simple versus complex.
The independent variables were gender, duration of episodes
(divided into less than 1 month, 1 to 3 months and over
3 months), the age of onset of the MD (after logarithmic
transformation), the average number of episodes per year
(after logarithmic transformation), and the age of testing. The
continuous variables were added to the model as covariates.
Finally, an analysis of the profiles of the MCMI-III
scales was performed with a repeated measures ANOVA,
encompassing the cluster found by the recursive partitioning
as a grouping variable and the elevations of the MCMI-III
scales as repeating measures.
All the other statistical analyses were performed with the
SPSS for Windows, Release Version 17.0, (SPSS, Inc., 2008,
Chicago, IL, http://www.spss.com/).
3. Results and Discussion
The final sample encompassed 209 patients (66 males and 143
females; mean age 55.48 SD 13.04). Sample characteristics and
clinical data relative to the MD are shown in Table 1 and also
allow comparison with the complexity of the PD.
3.1. MD Prevalence. Regarding Axis I diagnoses, 10.5% of
the patients had unipolar depression-single episode, 52.2%
unipolar depression recurrent, 22.5% bipolar type II disorder,
and 14.8% bipolar type I disorder.
4 ISRN Psychiatry
1
Age of onset
𝑃 = 0.03
≤29 y
Node 2 (𝑛 = 75)
1 1
0.8 0.8
0.6 0.6
0.4 0.4
0.2 0.2
0 0
No PD 1 PD >1 PD
Figure 1: Different patterns of the personality complexity defined by recursive partitioning analysis.
3.2. PD Prevalence. Regarding personality disorders, 17.2% of
patients had no elevated MCMI-III scores, 45.9% had one
peak, and 36.9% had two or more elevated values.
The prevalence of elevated scores (i.e., at least a scale with
a score of 85 or above) on the MCMI-III is 83% in the group of
patients with mood disorders. This value drops down to 77%
if one considers only patients with depressive disorder.
3.3. Recursive Partitioning. From the recursive partitioning
analysis, the age of onset of the MD was the most explicative
variable with a threshold of 29 years. Later on, the anal-
ysis found a further significant classification: the group of
participants over 29 years of age was divided according to
the duration of the episodes (under 3 months versus over 3
months). Consequently the type of MD was not significant
in the explanation of the different patterns of the personality
complexity (Figure 1).
The three patterns differed from each other on all of
the three levels of complexity of PD. In particular, node 2
is characterized by more than half the patients with high
complexity of PD (absolute majority of the node). The other
two nodes show for patients with later onset of the MD
a cluster (node 5) with high presence of PD (only 8% of
patients do not have a PD) represented by patients with longer
episodes (over 3 months) and a cluster of patients (node
4) with lower presence of PD and, more importantly, less
complexity (only 16% have a complex personality disorder).
The 𝜒2 test was highly significant (𝑃 < .001).
3.4. Predictors of Personality Complexity. The analysis was
applied to the participants with at least one MCMI-III
>29 y
3
Episode duration
𝑃 = 0.031
3 months or less More than 3 months
Node 4 (𝑛 = 85) Node 5 (𝑛 = 49)
1
0.8
0.6
0.4
0.2
0
No PD 1 PD >1 PD No PD 1 PD >1 PD
elevated value once more excluding patients diagnosed with
a single major depressive episode.
In Table 2, the results of the comparison between the two
groups are presented. Statistical significance of the age of
onset and the age of testing emerged.
The only statistically significant predictor emerging from
multivariate analysis was the age of onset of the MD (𝐹 =
8.945; 𝑑𝑓 = 1; 𝑃 = .003; 𝜂2 = .058). The significance of
the age of testing disappears: its connection to the complexity
of the PD was probably influenced by the age of onset of
the disorder itself. The duration of the episodes between
simple and complex disorders was not statistically significant,
and this difference did not improve its significance in the
multivariate analysis (𝐹 = 1.230; 𝑑𝑓 = 2; 𝑃 = .295; 𝜂2 = .017).
This led us to think it is not a mere type II error but more
likely a variable with heterogeneous distributions in both
personality disorder conditions.
3.5. Comparison of the Profiles of the MCMI-III Scales. The
profile comparisons (Figure 2) show statistically significant
differences between the three clusters based on PD complex-
ity (𝐹 = 9.346; (𝑑𝑓 = 2); 𝑃 < .01; 𝜂2 = .092) and so did the
interaction between cluster and MCMI-III profile (correction
of Huynh-Feldt (𝐹 = 3.640; (𝑑𝑓 = 14.357); 𝑃 < .001;
𝜂2 = .038)).
From the multiple comparisons with Bonferroni cor-
rections, the cluster of patients with early onset of MD
significantly differed from the cluster with later onset and
longer episodes, but it did not differ from the one with
shorter episodes. On the other hand, the cluster with later
MD onset and longer episodes significantly differed from
ISRN Psychiatry 5

Table 2: Comparison between PD Simple and PD Complex.

𝑁 = 157 PD Simplea (𝑁 = 87) PD Complexb (𝑁 = 70) 𝑃 Effect Size

Gender (F) 57 (65.5%) 51 (72.9%) .324 .006
Duration episodes >3 months 30 (34.5%) 34 (48.6%) .074 .020
Age of MD onset 39.62 (16.04) 31.47 (14.62) .001 .065
Number of episodes annual 0.59 (0.51) 0.68 (0.65) .314 .007
Age of survey 58.48 (12.48) 53.60 (13.91) .022 .033
MCMI-III Personality Disorder Elevationsc
(1) Schizoid 4 (4.6%) 3 (4.3%) .925 <.001
(2A) Avoidant 7 (8.0%) 30 (42.9%) <.001 .166
(2B) Depressive 1 (1.1%) 25 (37.1%) <.001 .224
(3) Dependent 11 (12.6%) 31 (44.3%) <.001 .126
(4) Histrionic 7 (8.0%) 10 (14.3%) .211 .010
(5) Narcissistic 9 (10.3%) 8 (11.4%) .828 <.003
(6A) Antisocial 0 (0.0%) 1 (1.4%) — —
(6B) Aggressive 1 (1.1%) 1 (1.4%) — —
(7) Compulsive 37 (42.5%) 24 (34.3%) .292 .007
(8A) Negativistic 4 (4.6%) 7 (10.0%) .187 .011
(8B) Self-defeating 0 (0.0%) 0 (0.0%) — —
S. Schizotypal 1 (1.1%) 2 (2.9%) — —
C. Borderline 4 (4.6%) 14 (20.0%) .003 .058
P. Paranoid 1 (1.1%) 9 (13.0%) .003 .057
a
Participants with one elevation on the MCMI-III.
b
Participants with more than one elevation on the MCMI-III.
c
Base rate ≥85.
𝜒2 and 𝜑2 were used for the comparison of categorical variables.
ANOVA 𝐹 test and 𝜂2 were used for the comparison of continues variables.

0.5 disorders with more impaired functioning. The clusters with

later onset differed in the three scales: avoidant, depressive,
Proportion of patients with

0.4 and dependent, partially differed from each other in the

complex disease

paranoid scale, and remained very close to each other in all

0.3
the other scales.
0.2

0.1
0
1 2A 2B 3 4 5 6A 6B 7 8A 8B S
Nodes
2 difference of personality traits between early and later onsets
4
5
Figure 2: Profiles of MCMI-III: comparison of three patterns of
personality complexity. Clinical personality patterns: 1: schizoid; 2A:
avoidant; 2B: depressive; 3: dependent; 4: histrionic; 5: narcissistic;
6A: antisocial; 6B: aggressive; 7: compulsive; 8A: negativistic; 8B:
self-defeating. Severe personality scales: S: schizotypal; C: border-
line; P: paranoid.
the other clusters. In particular, there was a clear difference
between the cluster with early onset and the other two. The
difference is seen in the elevation of the three last scales
representing, according to Millon [27], severe personality
4. Discussion
The aim of the present study was to explore the relationship
C P between the age of onset of MD and the complexity of the
personality traits of the patients. Moreover, we were inter-
ested in identifying an age threshold able to maximize the
and investigating the association between mood disorder
severity and personality traits.
To start with, the prevalence of the personality disorders
(PD) evaluated with the MCMI-III in patients admitted
for a depressive/hypomaniac episode through a dimensional
evaluation was higher than that in previous studies, regarding
both outpatients with a depression diagnosis and dimen-
sional evaluation [29] and patients with unipolar and bipolar
disorders [6, 16]. These results can be in part linked to the fact
that all the patients recruited for the present study had at least
one hospital admission, a strong indicator of worse severity of
the disorder.
In the recursive partitioning analysis, the age of onset was
the most significant predicting factor. Interestingly, the type
6 ISRN Psychiatry
of mood disorder was not a significant predicting factor, as
previously shown [20].
The threshold of onset was higher compared to previous
studies [21, 23, 33] while it overlaps with what was recently
highlighted about depressive disorders [24].
It is interesting to underline the relationship identified
between the severity of MD in terms of duration of episodes
and of PD, particularly in the cluster with later onset. More
complex PD are associated with longer MD episodes.
In early onset patients, the presence of maladaptive
personality makes more likely both the onset of an MD
and the creation of a more complex personality disorder
[19]. This interpretation could explain the independence
between the complexity of the PD (with the presence of the
elevations on the scales more often associated with severe
cases) and the severity of the MD. Conversely, in the later
onsets, the development of the particularly severe MD can
increase the personality symptomatology and elevate the
MCMI-III scale scores [35]. This is what can be found in
the three scales: avoidant, depressive, and dependent. In fact,
between the patients with later MD onset, the ones with
longer episodes have more elevations on these three scales,
while, on the other scales, except partially for the paranoid
scale, they are practically identical. In particular, avoidant and
dependent are two scales whose elevations are expected in
the presence of depressive disorder [36]. To date, it is not
possible to highlight a clear direction of causality for the
examined relationship and state whether the presence of a
more complex personality disorder condition is caused by the
onset of a more severe MD or influences the severity of the
MD itself (e.g., by reducing the presence of social support
around the patient). Thus, further studies are necessary to
clarify this relevant issue, as the presence of an MD as an
inclusion criterion and the difficulty to accurately establish an
age of onset for an MD do not allow any definitive conclusion.
The present study has some limitations. Firstly, the cross-
sectional design did not allow us to detect precisely how
the PD and MD developed. Secondly, as the assessment
was conducted at the end of admission period, we could
have found more PD than in the euthymic phase. Finally,
the use of a self-administered tool for the detection of the
PD may have led to an overestimation of the presence and
complexity of the personality traits, particularly in keeping
with the psychometric characteristics of the MCMI-III, as
described in a recent study on the topic (Zennaro, in press)
even if a conservative cutoff criterion was adopted. However,
MCMI-III (as other self-report inventories, e.g., Minnesota
Multiphasic Personality Inventory-2) has the advantage of
including validity scales that can detect possible patterns of
response sets, biases, and distortions that might compromise
the validity of the clinical assessment assuring specific quality
of data at the study [37].
5. Conclusions
This study has introduced the issue of disorder severity
aspects in the investigation of the relationship between MD
and PD. Our findings suggest that it is important to design
prospective studies able to evaluate the level of comorbidity
also on later MD onset patients and to include variables about
the severity of the disorders. From a clinical point of view,
the results suggest the need to assess maladaptive personality
traits not only during adolescence but also in young adults
too in order to prevent and treat potentially severe MD.
Acknowledgment
The authors especially thank Francesco Oliva and Diana
Francone.
References
[1] A. E. Skodol, M. T. Shea, S. Yen, C. N. White, and J. G. Gunder-
son, “Personality disorders and mood disorders: perspectives
on diagnosis and classification from studies of longitudinal
course and familial associations,” Journal of Personality Disor-
ders, vol. 24, no. 1, pp. 83–108, 2010.
[2] World Health Organization, “WHO The global burden of
disease: 2004 update,” WHO Press, Geneva, Switzerland,
2008, http://www.who.int/healthinfo/global burden disease/
2004 report update/en/index.html.
[3] D. J. Kupfer, “The increasing medical burden in bipolar disor-
der,” Journal of the American Medical Association, vol. 293, no.
20, pp. 2528–2530, 2005.
[4] American Psychiatric Association, Diagnostic and Statistical
Manual of Mental Disorders: DSM-IV-TR, American Psychiatric
Association, Arlington, VA, USA, 4th edition, 2000.
[5] A. E. Skodol, J. G. Gunderson, T. H. McGlashan et al., “Func-
tional impairment in patients with schizotypal, borderline,
avoidant, or obsessive-compulsive personality disorder,” Amer-
ican Journal of Psychiatry, vol. 159, no. 2, pp. 276–283, 2002.
[6] P. Brieger, U. Ehrt, and A. Marneros, “Frequency of comorbid
personality disorders in bipolar and unipolar affective disor-
ders,” Comprehensive Psychiatry, vol. 44, no. 1, pp. 28–34, 2003.
[7] M. V. Christensen and L. V. Kessing, “Do personality traits
predict first onset in depressive and bipolar disorder?” Nordic
Journal of Psychiatry, vol. 60, no. 2, pp. 79–88, 2006.
[8] C. J. Ruggero, M. Zimmerman, I. Chelminski, and D. Young,
“Borderline personality disorder and the misdiagnosis of bipo-
lar disorder,” Journal of Psychiatric Research, vol. 44, no. 6, pp.
405–408, 2010.
[9] R. T. Mulder, “Personality and depression: a commentary,” The
Canadian Journal of Psychiatry, vol. 53, no. 1, pp. 3–5, 2008.
[10] B. F. Grant, S. P. Chou, R. B. Goldstein et al., “Prevalence,
correlates, disability, and comorbidity of DSM-IV borderline
personality disorder: results from the Wave 2 national epidemi-
ologic survey on alcohol and related conditions,” Journal of
Clinical Psychiatry, vol. 69, no. 4, pp. 533–545, 2008.
[11] F. S. Stinson, D. A. Dawson, R. B. Goldstein et al., “Prevalence,
correlates, disability, and comorbidity of DSM-IV narcissistic
personality disorder: results from the wave 2 national epidemi-
ologic survey on alcohol and related conditions,” Journal of
Clinical Psychiatry, vol. 69, no. 7, pp. 1033–1045, 2008.
[12] A. J. Pulay, F. S. Stinson, D. A. Dawsin, R. B. Goldstein, S. P.
Chou, M. D. Huang et al., “Prevalence, correlates, disability, and
comorbility of DSM-IV schizotypal personality disorder: results
from the Wawe 2 national epidemilogic survey on alcohol and
related conditions,” Journal of Clinical Psychiatry, vol. 11, no. 2,
pp. 53–88, 2009.
ISRN Psychiatry 7

[13] G. Newton-Howes, P. Tyrer, and T. Johnson, “Personality disor- [29] M. A. Craigie, L. M. Saulsman, and A. M. Lampard, “MCMI-
der and the outcome of depression: meta-analysis of published III personality complexity and depression treatment outcome
studies,” The British Journal of Psychiatry, vol. 188, pp. 13–20, following group-based cognitive-behavioral therapy,” Journal of
2006. Clinical Psychology, vol. 63, no. 12, pp. 1153–1170, 2007.
[14] M. Schou, “No help from lithium? About patients who might [30] F. Faul, E. Erdfelder, A. G. Lang, and A. Buchner, “G∗ Power 3: a
have been but were not helped by prophylactic lithium treat- flexible statistical power analysis program for the social, behav-
ment,” Comprehensive Psychiatry, vol. 29, no. 2, pp. 83–90, 1988. ioral, and biomedical sciences,” Behavior Research Methods, vol.
[15] F. Colom, E. Vieta, A. Martinez-Aran, M. Reinares, A. Ben- 39, no. 2, pp. 175–191, 2007.
abarre, and C. Gasto, “Clinical factors associated with treatment [31] L. Breiman, Classification and Regression Trees, Wadsworth
noncompliance in euthymic bipolar patients,” Journal of Clinical International Group, Belmont, CA, USA, 1984.
Psychiatry, vol. 61, no. 8, pp. 549–555, 2000. [32] T. Hothorn, K. Hornik, and A. Zeileis, “Party: a Laboratory for
[16] E. L. George, D. J. Miklowitz, J. A. Richards, T. L. Simoneau, recursive partytioning,” 2011, http://www.R-project.org/.
and D. O. Taylor, “The comorbidity of bipolar disorder and [33] T. Hothorn, K. Hornik, and A. Zeileis, “Unbiased recursive
axis II personality disorders: prevalence and clinical correlates,” partitioning: a conditional inference framework,” Journal of
Bipolar Disorders, vol. 5, no. 2, pp. 115–122, 2003. Computational and Graphical Statistics, vol. 15, no. 3, pp. 651–
[17] P. R. Joyce, J. M. McKenzie, J. D. Carter et al., “Temperament, 674, 2006.
character and personality disorders as predictors of response [34] R Development Core Team, “R: a language and environment for
to interpersonal psychotherapy and cognitive-behavioural ther- statistical computing,” R Foundation for Statistical Computing,
apy for depression,” The British Journal of Psychiatry, vol. 190, pp. Vienna, Austria, 2011, http://www.R-project.org/.
503–508, 2007. [35] J. P. Choca, Interpretative Guide to the Millon Clinical Multiaxial
[18] P. M. Lewinsohn, J. L. Steinmetz, D. W. Larson, and J. Franklin, InvenTory, American Psychological Association, Washington,
“Depression-related cognitions: antecedent or consequence?” DC, USA, 3rd edition, 2004.
Journal of Abnormal Psychology, vol. 90, no. 3, pp. 213–219, 1981. [36] A. Farabaugh, D. Mischoulon, M. Fava, W. Guyker, and J.
[19] R. T. Mulder, “Depression and personality disorder,” Current Alpert, “The overlap between personality disorders and major
Psychiatry Reports, vol. 6, no. 1, pp. 51–57, 2004. depressive disorder (MDD),” Annals of Clinical Psychiatry, vol.
[20] F. Benazzi, “Classifying mood disorders by age-at-onset instead 16, no. 4, pp. 217–224, 2004.
of polarity,” Progress in Neuro-Psychopharmacology and Biolog- [37] T. A. Widiger and D. B. Samuel, “Evidence-based assessment of
ical Psychiatry, vol. 33, no. 1, pp. 86–93, 2009. personality disorders,” Psychological Assessment, vol. 17, no. 3,
[21] M. Fava, J. E. Alpert, J. S. Borus, A. A. Nierenberg, J. A. pp. 278–287, 2005.
Pava, and J. F. Rosenbaum, “Patterns of personality disorder
comorbidity in early-onset versus late-onset major depression,”
The American Journal of Psychiatry, vol. 153, no. 10, pp. 1308–
1312, 1996.
[22] A. E. Skodol, R. L. Stout, T. H. McGlashan, C. M. Grilo, J.
G. Gunderson, M. T. Shea et al., “Co-occurrence of mood
and personality disorders: a report from the Collaborative
Longitudinal Personality Disorders Study (CLPS),” Depress
Anxiety, vol. 10, no. 4, pp. 175–182, 1999.
[23] R. H. Perlis, E. B. Dennehy, D. J. Miklowitz et al., “Retrospective
age at onset of bipolar disorder and outcome during two-year
follow-up: results from the STEP-BD study,” Bipolar Disorders,
vol. 11, no. 4, pp. 391–400, 2009.
[24] J. D. Bukh, C. Bock, M. Vinberg, U. Gether, and L. V. Kessing,
“Differences between early and late onset adult depression,”
Clinical Practice and Epidemiology in Mental Health, vol. 7, pp.
140–147, 2011.
[25] M. B. First, R. L. Spitzer, M. Gibbon, and J. B. W. Williams, Struc-
tured Clinical Interview For DSM-IV Axis 1 Disorders Patient
Edition (SCID-I/P Version 2. 0), New York State Psychiatric
Institute, Biometrics Research Department, New York, NY,
USA, 1995.
[26] J. Lobbestael, M. Leurgans, and A. Arntz, “Inter-rater reliability
of the structured clinical interview for DSM-IV axis I disorders
(SCID I) and axis II disorders (SCID II),” Clinical Psychology
and Psychotherapy, vol. 18, no. 1, pp. 75–79, 2011.
[27] T. Millon, Millon Clinical Multiaxial Inventory-III Manual,
National Computer Systems, Minneapolis, MN, USA, 1994.
[28] A. Zennaro, S. Ferracuti, M. Lang, and E. Sanavio, “Una
rivoluzione nell’assessment clinico della personalità,” in Adatta-
mento italiano del test: Millon Clinical Multiaxial Inventory—III,
Giunti OS, Florence, Italy, 2008.
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